Choices for the Future

All countries are continuing to search for better cost-containment and cost-effectiveness mechanisms, including the difficult task of placing limits on the healthcare technologies that provide small marginal benefits to a few individuals at a great cost to the community.

Tension will grow between the values of individual autonomy (reflected in the assumption by patients that the right to healthcare includes all interventions that are of possible benefit and the assumption by providers that they have the right to set prices and choose where and whom to serve) and concern for the good of the community and other societal needs. Attempts to achieve equality in the systems of financing, payment, cost control, and delivery will have to take into account increasing competition for limited resources and the perceived infringement on personal freedom. Balancing these competing claims will be especially difficult in the United States with its multiple systems and distrust of government involvement in human services.

A renewal of a sense of community and a careful balancing of values will be necessary in achieving a reasonable solution. Although the future is unclear, the United States probably will reconsider policies for rational allocation between healthcare and other sectors of the economy, government regulation to require universal and equitable access to defined basic insurance policies, mandated employer-based insurance with a publicly financed safety net, payment based on capitation with some adjustment for the severity of illness in a specific group of patients, and incentives (including scholarships and loan forgiveness) for providers who choose to provide primary care in shortage areas.

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